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Healthcare InsuranceReimbursement Claim Form
One Claim Form per person, family members must apply
individually.For the required supporting documentation, use the
attached Summary Table as cover sheet.Before you submit, check your
Table of Benefits in your policy document for exclusions to avoid
rejections.Please write in BLOCK LETTERS, complete in full and
submit within 30 days to ensure timely processing.
1. Member and Payment Details Form Number
Claimant Name Employer
Card Number Policy Number
Email Address Mobile 0 5
Principal Member Employee #
Bank Account Name Bank A/C #
Bank Name Branch
IBAN (23 digits)
2. Claim DetailsIs the claim in UAE? Yes No If No, precise
Country
Name of Hospital/Dr.
Date of Treatment / / 1 Number of Invoices
Total Amount Claimed Currency
For breakdown of Total Amount Claimed, use attached summary
table cover sheet to tabulate entries in chronological order.
3 Medical Details to be completed by the treating Doctor
58631396
Jasmin Alok Singh Wood Group Keny
OIG/ME-24221/S/6038635
[email protected] 6 6 6 3 0 5 7 0
Alok Kumar Singh 2 4 8
Alok Kumar Singh 798275141001
Abu Dhabi Commercial Bank Abu Dhabi Main Branch
A E 2 1 0 0 3 0 0 0 0 7 9 8 2 7 5 1 4 1 0 0 1
A E D
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3 Medical Details to be completed by the treating Doctor
Healthcare InsuranceHow to Complete the Form
Both you and the attending doctor must fill in the claim form
for eachindividual visit or course of treatment.
You
1. The Patients details section is to be filled
completelyincluding the Policy Number and the Card Number.Give us
your contact details so we can keep you informed onthe progress of
your claim by SMS or by e-mail.Enter the bank details including the
IBAN of the accountwhere we can transfer your settled claim
amount.
2. Include the breakdown of expenses that
needreimbursement.Complete the summary table on the next page
giving the full
required details. Every invoice should be on one line.3. Read
the Declaration section carefully, tick the boxes andremember to
sign and date the form.
Your Doctor4. Please ensure that the doctor completes each
question of the
Medical section in full and then signs and stamps it.
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Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125,
C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984
Head Office: P.O. Box 5209, Dubai, United Arab Emirates. Tel.:
800 4746, Fax: +971 4 233 7775, www.tameen.ae
Reimbursement Claim Form AttachmentSummary Table of Invoices
Mark the sequence number of the corresponding invoice.
SequenceNumber
Service Date Provider Name Service Description Invoice ref.
NumberClaimedAmoun t
Currency
In case you have more invoices to send, please photocopy this
sheet.
Checklist - Before you submit, please check that you have
included all of the following as applicable:
1. Completed, stamped and signed Reimbursement Claim Form
2. Pre-approval letter form Oman Insurance company where
required (refer to TOB)
3. Original invoices/bills showing payments confirmation
4. Medical and/or Lab test reports
5. All claims submitted must be in original & translated to
either English or Arabic for the settlement
6. Card copy of the concerned member.
7. Summary Table of Submitted Invoice (above) completed
8. You have retained a copy of the Form, Summary Table and
original invoices and report for your reference
